The referenced Report form is to be used by every department/agency of
the City of Baton Rouge and Parish of East Baton Rouge to record any: (1) ACCIDENT
involving any City Parish vehicle or piece of equipment that causes damage or injury; (2)
Other workplace accident resulting in INJURY OR ILLNESS to a City Parish employee; or (3)
SERIOUS INCIDENTwhich is an incident or near accident where that is NO DAMAGE OR
INJURY, but where significantdamage or serious injury could have
resulted.

The purpose of this report is to assist the appropriate safety officer
in determining the cause of an accident or incident in order to take steps to
prevent a recurrence, if possible. There is no intent to find fault with any
employee. This report will also be utilized in the reviewing of accidents that are brought
before the Accident Review Committee and Accident Appeal Board.

The first section (pages 1-3) is to be fully filled out and signed by
the employee involved in the accident/incident. This section simply gives the employee the
right and freedom to explain, in his/her own words, what happened and to express his/her
opinion as to the cause and how the accident/incident could have been prevented. The
details of this section are crucial in the investigation of the accident/incident, if this
type of accident/incident is to be avoided in the future. By signing the form the employee
is verifying that the information is his or her account of the accident/incident. Even if
the employee has someone assist with the form, the employees signature verifies the
information came from him/her. Please keep in mind that the form should be completed with
BOTH the employee and supervisor together.

The last section (page 4) is to be filled out and signed by the
employees supervisor.

Any employee operating a City Parish vehicle or piece of
equipment at the time of an accident/incident; or who is injured on duty; or who causes
an on-duty accident/incident or injury shall immediately complete the first
section with his/her supervisor present. The supervisor would then complete
the last section and submit a copy of the form to the appropriate appointing
authority or safety officer. The original should be sent to the Risk
Management Division of the Parish Attorney Office for review, assessment
and possible recommendations for safety policies.